Instant Messaging Telemedicine and Patient Records: Will Reality Drive Process? Maurice Mars, Chris Morris and Richard Scott Dept of TeleHealth, Nelson R Mandela School of Medicine University of KwaZulu-Natal, South Africa

Legal and Ethical Prior relationship Written consent Confidentiality Records at both ends Encryption Quality of images Security

Records at Both Ends 4.9.3 The patient’s records established during the use of telemedicine must be accessible and documented for both the healthcare practitioners involved and their patients.

“Does mHealth optimise what we know works?” Alain Labrique

Some Questions Do you have a smartphone? Do you have WhatsApp or similar app? Are you in a WhatsApp group for your Dept? Have you used WhatsApp for telemedicine? If not, do you know anyone who has?

When is a Telemedicine Service Deemed Successful? Integration of telemedicine activities into routine clinical practice eg Radiology

J Telemed Telecare 2005

18 Factors Strategy and management Organisation and management Legal regulatory and safety Technical and infrastructural

J Telemed Telecare 2009 BMC Med Inform Decision Making 2012

Current Best Practice Telemedicine strategy Needs assessment Choose appropriate solution eReadiness Business plan / sustainability Implementation plan Evaluation Refinement Scale up

Spontaneous Service? Is it doomed because it is not planned? Is it an indication of maturity – needs have led to a solution? Should it be supported? What is needed to support it?

KwaZulu-Natal

Email Services 2003: Failed – limited Internet access

Synchronous Teledermatology Consultation Since 2005 Videoconference No peripheral devices Four rural hospitals Monthly sessions 72% saved referral

2008: Failed – extra work and suspicion? Email Services 2008: Failed – extra work and suspicion?

Spontaneous Services – mDermatology 2013 Mobile phone: camera and transmission

Spontaneous Services – mDermatology 2013 Trainees seeking advice Rural Drs seeking advice Cell phones used for WhatsApp and photos Stored on specialist’s phone or tablet No paper record / audit trail Benefit - fewer outpatients

KwaZulu-Natal 7- 10,000 burns / year Require + 450 beds Have + 120 burns beds Remainder - surgical beds Problems with initial management

Referral Policy – Unit beds and clinic Telephone referral Pre-admission form Dumping syndrome Overestimate area Underestimate depth Decision

Spontaneous Services – mBurns Specialist not available for assessment of burn wounds at dressing changes Photo’s on cell phones by junior Drs and nurses Viewed on cell phones 3 year experience

Referral Policy – Unit beds and clinic December 2014 Pre-admission call Require photographs Sent by WhatsApp Response SMS / WhatsApp Telephonic and WhatsApp support if not-accepted

Two cases – no series reported mBurns J Telemed Telecare 2006 Two cases – no series reported

mBurns First 116 cases - photo altered the management in two thirds of cases

WhatsApp Service Concerns Legal and Regulatory issues Confidentiality Encryption Data security Data storage Record keeping Evidence of consent Prescription

1,000,000,000 users (Feb 2016) Proprietary, free, instant messaging app Works across operating systems Allows text, image, video and audio messages One to one communication or One to many “group” chats

Ex Africa Semper Aliquid Novi WhatsApp Literature Review 41 papers – 10 countries 15 disciplines WhatsApp Groups 16 (14 surgery) Papers emergency triage – no groups Simple, cheap and effective Pliny the Elder 23 - 79 AD

10 Countries India 12 UK 5 Saudi Arabia 3 Italy 4 Turkey 2 Spain 2 Brazil 1 Netherlands 1 Philippines 1 USA/RSA 1

Consent – 5 Taking photos and sharing with group 2 Taking photos 3 Burns ? Dermatology?

Record Keeping - 1 Implied – not stated “no longer lose X-Rays” BUT Can email chats No mention of this KZ-N Burns – enter data

Data Security

End to End Encryption? WhatsApp Server √ √ Android One to one text

√ X End to End Encryption? WhatsApp Server Android One to one image One to chat group iOS and Windows all messages

End to End Encryption?

End to End Encryption? Messages between WhatsApp users are protected with an end-to-end encryption protocol so that third parties and WhatsApp cannot read them and so that messages can only be decrypted by the recipient. All types of WhatsApp messages (including chats, group chats, images, videos, voice messages and files) and WhatsApp calls are protected by end-to-end encryption.

very commendable, but the only law that applies is the “The laws of mathematics are very commendable, but the only law that applies is the law of Australia.” Malcolm Turnbull - Prime Minister

“Does mHealth optimise what we know works?” Alain Labrique

Spontaneous Services Is this the new face of telemedicine success in the developing world? Is telemedicine too regulated for this in the developed world?

Legal and Ethical Prior relationship Written consent Confidentiality Records at both ends Encryption Quality of images Security

Legal and Ethical 4.9.3 The patient’s records established during the use of telemedicine must be accessible and documented for both the healthcare practitioners involved and their patients.